Spring Break Day Camp Registration

Please select the K-2nd grade sessions the student will be attending. If your student is enrolling in 3rd-5th grade sessions, please select "None."*

Eggstravaganza (3/26/18) AM

Home Tweet Home (3/26/18) PM

Map Quest (3/27/18) AM

Trading Post (3/27/18) PM

Raiders of the Lost Artifact (3/28/18) AM

Buried Secrets (3/28/18) PM

Animalympics (3/29/18) AM

Tinker Time (3/29/18) PM

Minecraft (3/30/18) AM

Block Party (3/30/18) PM

None

Please select the 3rd-5th grade sessions the student will be attending. If your student is enrolling in K-2nd grade sessions, please select "None."*

Eggstravaganza (3/26/18) AM

Home Tweet Home (3/26/18) PM

Map Quest (3/27/18) AM

Trading Post (3/27/18) PM

Raiders of the Lost Artifact (3/28/18) AM

Buried Secrets (3/28/18) PM

Animalympics (3/29/18) AM

Tinker Time (3/29/18) PM

Minecraft (3/30/18) AM

Block Party (3/30/18) PM

None

Parent/Guardian Name*

Parent/Guardian E-mail*

Address*

Street AddressAddress Line 2CityStateZIP Code

Parent/Guardian Phone #*

Parent/Guardian Alternate Phone #*

Emergency Contact Name*

Emergency Contact Relationship To Student*

Emergency Contact Phone #*

Emergency Contact Alternate Phone #*

Does the student have any medical conditions or allergies?*

Yes

No

If you answered yes to the question above, please describe these medical conditions/allergies.

Preferred physician/hospital*

Insurance Policy Number*

By submitting this form, you give The National Mississippi River Museum & Aquarium/Dubuque County Historical Society (NMRMA/DCHS) authorization to obtain necessary medical treatment in the case of any emergency situation that may arise if the indicated emergency contact is not able to be reached at the time of such emergency. You also agree that in no event will the NMRMA/DCHS be held liable for any injuries, accidents or losses suffered by my child/the participant while participating in any supervised programs and the NMRMA/DCHS is hereby released from liability. In addition, you authorize the NMRMA/DCHS to photograph the registered participant for the reasonable use and purpose of promotional advertising.